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VMC Renton, Washington: where death happens and no one seems to care

STAFFING ISSUES AND THE LACK OF PRIORITIES


DOCTOR STAFFING ISSUES

November 15 to November 18: Dr. Christopher DiRe never stops by to talk to me about Mark’s pancreatitis – he does however bill for it (and I was there in Mark’s room). I finally see Dr. Christopher DiRe on December 19 and tell him, “isn’t it a little late in the game for yet another new doctor?” not realizing he had billed for his (non) services earlier.

November 17: Around 3:30 Dr. Suzanne Krell shows up and clearly appears agitated (because I asked where she was). The VMC staff in Mark’s room look down (away from her like they are in fear) and scramble like mice. Dr. Suzanne Krell tells me she came by the previous day and I was not here. I explained to Dr. Suzanne Krell that I was here all day long; left to shower and eat dinner then came back. I mention my concern about Mark getting MRSA in his lung; it’s definitely from the respirator. Dr. Suzanne Krell tells me “that is the least of his problems. He also has an Enterobacter Cloacae infection in his lung.” This is the first I have heard of this. Dr. Suzanne Krell goes on to tell me (and she snips) that she has “26 PATIENTS” AND DOES NOT HAVE THE TIME TO GIVE THEM ALL 30 MINUTES.” And Dr. Suzanne Krell works in an ICU?

November 17: I take this photo because of the lack of tie-in with the staff and what I have to do for them to understand what my expectations are.

November 19: Dr. Stephanie Nunez informs us that she has 26 patients - Wayne tells Dr. Stephanie Nunez “YOUR STAFFING ISSUES ARE OF NO CONCERN TO US – TALK TO YOUR SUPERVISOR.”

December 8: The nurse goes and gets Dr. William Park (because we, the nurse and I, disagree over giving Mark Versed – which is against Dr. Lindy Klaff’s orders due to the side effects). Dr. William Park comes in the room and says he has “too many patients to deal with this, not enough time.” I tell Dr. William Park that Dr. Lindy Klaff said not to give Mark Versed ~ he asks me why instead of reading the orders. Dr. William Park goes against Dr. Lindy Klaff’s orders and says “he is fine with Mark getting Versed (Midazolam).”

December 20:
Dr. Richard Wall says the intensivist will be the “Quarterback” for the team of VMC doctors. Dr. Richard Wall writes this order and from this point (December 20th) until Mark’s death a hospitalist never sees Mark again; no GI’s see Mark from December 20 until December 29 (and remember Mark has pancreatitis, gallstones, and his liver is shocked/failing from the medications).
How long do you think Dr. Richard Wall saw my son after these orders? FOR THREE DAYS MORE AND NEVER AGAIN – NO ONE VMC DOCTOR WAS MARK’S “QUARTERBACK” LIKE  Dr. Richard Wall TOLD US THEY WOULD BE. Do you think I would trust this doctor again?

December 20 to December 29: No VMC GI doctors see and monitor Mark. These 5 VMC GI doctors were SUPPOSED TO BE monitoring Mark’s pancreatitis (Doctors Christopher DiRe, Eric Yap, Daniel O’Neill, William Pearce, Duane Carlson and Frank Thomas). Mark also had documented gallstones on November 26 (which none of them read the report – which caused the pancreatitis). Of note is that when the lab report was available, Dr. Frank Thomas was in charge (November 27). None of these doctors went against Dr. Richard Wall’s orders and expressed the urgent need for a GI to follow Mark because they are (supposed to be anyway) specialists in this area – a lung doctor isn’t. 

January 7: The nurse and I go to turn Mark to his side so the wound nurse can change the bandages for Mark’s bed sores (which were preventable). Mark is on his side for about 5 minutes and by the time we turn him back over there is a huge amount of bile all over the blue sling that is beneath him and the large bandage that is over Mark’s G-tube (Tegaderm like bandage) is literally full of fluid. I ask one of the nurses to tell Dr. William Park; they don’t. I ask the nurse to page Dr. Daniel O’Neill; she does. I tell the nurse to talk to Dr. Daniel O’Neill first (to explain what happened in a technical manner) and then I would like to talk to him. Dr. Daniel O’Neill calls and talks to the nurse but says “he is too busy to talk to me even though something as critical as this happened.”  Dr. Daniel O’Neill eventually calls me later this evening – when “he has time.”

January 9: Mark is in a lot of pain now and is belching massively. Jed goes to change the bandage on Mark’s G-tube incision and I see a light green bubbling/oozing fluid (bile) dripping down Mark’s side. At his same time I see Dr. Amy Morris and Dr. Daniel O’Neill in the hallway and ask them both to come in to Mark’s room and look. Dr. Amy Morris  “is too busy;” Dr. Daniel O’Neill comes in (without gowning and putting on gloves) and removes the bandage. Dr. Daniel O’Neill looks very concerned. Dr. Daniel O’Neill says this is common and moves the G-tube around a bit; he may have to consider a pancreatic drain. Mark is in a lot of pain even after Jed gave him the Fentanyl. Dr. Daniel O’Neill says that to replace that G-tube Mark would have to be moved to some type of acute place. Dr. Daniel O’Neill suggests putting the suction (instead of gravity) on the stomach fluid drain. Jed does. I mention Mark’s abdomen and thighs looking like they will burst; Dr. Daniel O’Neill says he will talk to Dr. Amy Morris and see if there are areas that can be drained in Mark’s abdomen. I ask Dr. Daniel O’Neill where all the drainage is coming from (is it his stomach or bile in his abdomen leaking out?). I get no answer.

A little later Mark starts foaming at the mouth massively and burping quite a bit. I now hear the suction/gurgling coming out of the incision. Mark keeps rubbing his stomach and is in a lot of pain.

January 10: I ask Mary to page Dr. Christopher DiRe. Dr. Christopher DiRe shows up at ~12:30 and tell him about Mark foaming at the mouth, massive gas, belching, rectal tube bag being full of gas, the gurgling feces between Mark’s legs (on the bed) and about the G-tube incision discharge gurgling (you can hear air in there). Dr. Christopher DiRe says this all has to do with the complex nature of fluid collection and that it is possible that the stomach fluid got into his abdomen. I told him this all started right after the Bronchoscopy performed by Dr. Amy Morris. I ask about the stomach fluid sample that Jed took the day before and Dr. Christopher DiRe says it has amylase in it. I also mention gallbladder stones (Dr. Christopher DiRe has no idea that these showed up back in November). I have to show Dr. Christopher DiRe the lab (and Dr. Christopher DiRe looks up on the computer).

January 14: We are having probably our last family meetings (because of Mark’s condition) with the VMC ICU doctors and staff. I am told right before our meeting that Dr. William Pearce (a GI that has been following Mark / communicating with us about Mark’s condition) is not available and that they are sending Dr. Duane Carlson (who has seen Mark and talked to me for 2 minutes [and that is generous] during Mark’s stay at VMC). We have serious questions to ask about Mark’s gastrointestinal issues and VMC sends the doctor that is the least intimate with Mark and what has transpired.

Note: right before this meeting I go down to get coffee - I see Dr. William Pearce in the lunchroom at 12:20 pm ~ he is standing behind me in the checkout line.

So, Dr. William Pearce wasn’t available because he was eating lunch and his patient, Mark, is dying?

NURSING STAFFING ISSUES

Trainees / Temporary Workers on an ICU Floor?

November 14: Patsy, the “IV pump button pusher” is a temp nurse that has been here for 2 HOURS. I tell the Japanese nurse who is supposed to be the temp nurse’s mentor (also a temp nurse that hadn’t been to VMC ICU in a couple years) that it wasn’t fair to Mark or the other temp nurse to put her into this situation without support (not knowing how to operate the iv pump equipment). Three iv pump alarms went off with maddening sounds and the nurse kept pushing any button she could find AND her mentor was no where around. We were frightened Mark would be the victim of an overdose so we stay there all night to watch Mark (and the nurses). Why did this happen? A temp/trainee should never be left alone on an ICU ward floor.

Restraints (sedatives and straps):

November 16: The nurse likes the straps quite a bit and makes sure they are REAL tight on Mark's arms and legs. Also, a male nurse, Ed, was being overly aggressive in how he was handling Mark. I felt that Ed liked being aggressive a little too much – Ed clearly like the straps. Ed was rude, and did not understand how we (the family) have contributed in Mark’s care (moving, changing, grooming, etc.) and told us to leave the room and ripped the drape closed behind us. Ed, you need serious training.

I think Mark needs to sit up more; he is tightly strapped down to the bed; he is trying to stretch legs, back and arms; he is restless, his fingers don’t grip anymore and the nurses seem to think he is trying to “rip off” those tubes and/or escape…so they continuously zap him with more sedatives. We voice our concerns to the doctors and staff.

November 19: At 3:08 pm (Jane is at lunch) Mark’s breathing is very labored and it is making a very strange sound. I go out and get Jane’s back up, and tell her the IV pump and respirator are both going off, and something is wrong with Mark’s breathing. She comes in the room tries to suction out his lungs. I ask her to call the respiratory folks, she does then hangs up. I ask her if they are coming up, she says he is busy writing up a report with someone, I tell her to call him back or give me the number to call. The nurse yells at Mark “MARK” “YOU ARE OVER REACTING” about 5 times, then zaps Mark with 2 bolus of sedatives. Of course the sound and labored breathing do not stop; Mark is NOW UNCONSCIOUS from the sedatives. I tell her to call respiratory back, she does and Dan arrives. After inspection Dan finds out that there is a crack in one of the tubes and he puts tape on it. I ask why Mark is out; the nurse says that the first bolus she gave him didn’t work, so she gave him another.

A little while later, Mark starts struggling again. This time I go down the hall to see if I can find Dan versus getting the back-up nurse involved. I see Jane coming back from lunch and ask her to PLEASE COME, SOMETHING IS VERY WRONG WITH MARK AND HIS BREATHING.” She does. Jane calls Dan; he arrives and does another inspection. I leave the room, go around the corner because I am very shaken up and by the time I get back to Mark’s room
Dr. Stephanie Nunez and 4 or 5 other people are with Mark getting ready to pull out the respirator and place a new one. Apparently the balloon type of device that holds it in place and keeps air from seeping out has failed. They have to paralyze Mark for about 20 minutes to get it placed. I tell Dr. Stephanie Nunez that I told the nurse something was wrong, she yelled at Mark to stop over-reacting ~ zapped him with sedatives. Dr. Stephanie Nunez tells me “well, I wasn’t there” and I Dr. Stephanie Nunez “I was.” The nurse is watching all this happen and comes by and stands by me and I tell her “YOU were wrong.” The nurse says “I didn’t know.” I respond by telling her “I’m not in the health care business and I KNEW something was wrong by the sound. I sure hope you didn’t kill him.” The nurse says “sorry” and walks off.

December 8: The nurse goes and gets
Dr. William Park (because we, the nurse and I, disagree over giving Mark Versed – which is against Dr. Lindy Klaff’s orders due to the side effects). Dr. William Park comes in the room and says he has “too many patients to deal with this, not enough time.” I tell Dr. William Park that Dr. Lindy Klaff said not to give Mark Versed ~ he asks me why instead of reading the orders. Dr. William Park goes against Dr. Lindy Klaff’s orders and says “he is fine with Mark getting Versed (Midazolam).”

December 9: Cheryl comes in (Karyn is at lunch) and says the Fentanyl is almost out (iv drip line). Cheryl says Mark gets 50 mcg per hour and that she can’t get any more from the pharmacy. Cheryl goes to the other side of Mark’s bed with a shot of Fentanyl and says she will give him 50 mcg. I ask, “SO, you’ll give Mark the full dose for 1 hour?” Cheryl snips that “she doesn’t have time to stand there for 1 hour and give him a drop per minute” and “she isn’t going to give Mark something that will hurt him.” Cheryl is very unprofessional and it’s obvious that she heard that another nurse and I had issues with the Versed yesterday. At this same time the Physical Therapy gal comes in and asks if this is a good time, I tell her “no” because he will probably take a nap now because of the shot Cheryl gave him. Cheryl snips back “I didn’t sedate him, he can participate.” I say to Cheryl, “Gee, I wonder where this came from.” I also tell the PT gal “this is what I have to deal with.”

Are VMC doctors orders really followed?


January 3: I find out the nebulizer was to be stopped today, but I guess respiratory didn’t see the revised orders and gave Mark the morning dose.

January 4: Issues with the timing of the blood transfusions ~ The evening nurse and
Dr. William Park both say (to the day nurse) to give Mark the blood transfusion before his procedures (liver biopsy / G-tube placement) today. The days nurse says giving Mark the transfusions after procedures is ok, and that is exactly what she does; goes against Dr. William Park’s orders.

The Staff are apprehensive

December 20:
Bob Chapman, Rn explains that he had email from a nurse (on the Fentanyl issue). He also said that the staff are apprehensive about caring for Mark because of my questioning, note taking, and typing on my laptop. I tell Bob Chapman, Rn I will continue with my note taking and questioning. Bob Chapman, Rn also wants to know what we need for our daily tie-in: I tell him a daily tie-in with the Rn, a pre-procedure tie-in (Rn and doctor), all tie-in’s any patient or patients advocate would request.

Lack of priorities / complacency in the VMC ICU

November 21: Cheryl, the nurse “gives us training” on the alarms in Mark’s room. She explains to us that if certain iv pump alarms go off, she will not be responsive because she knows what that means (i.e. if a drug runs out and isn’t needed any longer she will let the alarm keep sounding until she has time to get to it). Is the alarm sounding stressful for the patient and family? You bet it is. I quickly learn what all the equipment is in the room, how it is operated and what each alarm means; this way I can silence the alarm and inform the nurse (because they don’t want to bothered per Cheryl) so Mark can rest and not be frightened of the sounds.

December 14: Mark’s fever goes to 105. The nurse doesn’t respond for around 45 minutes. Mark does not break out in a sweat. Mark is shaking rapidly. Come to find out later, Pseudomonas is identified today in Mark’s stool (which I’m never told about).

December 20: The nurse today is gone from the room more than normal; I’ve hardly seen her ~ and this is an ICU ward.

December 31: Today is a bad day in the ICU. It’s almost like they didn’t staff with the proper amount of nurses. Mark’s heart rate drops into the 20’s today (during dialysis) and sounds the alarm. The nurse doesn’t even come to the room (finally around noon). I go and look for
Bob Chapman, Rn and/or Tina (Rn supervisors) and both are gone. We talk to the charge nurse and apparently Mark’s heart rate dropping happened 2 times this morning before I arrived and last night so they aren’t concerned – Mark’s heart should recover, so I’m told.

January 3: I need to discuss priorities of Rn’s to
Bob Chapman, Rn:

“When the oxygen level, heart rate and BP alarms are sounding…it might be more of a priority to take care of those first before you get a sample of poop from the rectal tube.” Don’t you think??

January 4: The nurse finally gives Mark some pain meds ~ as he is yelling out in pain for about 30 minutes…she logs the meds into the computer first…then gets all her syringes ready and nicely lined up…then administers them. QUESTION FOR
BOOB Chapman, Rn: is this a good process or could the nurse have administered the drugs first, then logged onto the computer so Mark wasn’t agonizing in pain for that extra time? I’ve seen other nurses do this, why does this nurse drag her feet so much? She hardly goes into Mark’s room this day.

January 4: Mark’s bed is an air mattress. Mark is brought back from getting a liver biopsy, x-ray and G-tube placement and is brought back to the room. Instead of the nurse turning on the air mattress bed (which is like lying on concrete), the nurse goes and starts putting up equipment first. I try and start the bed up myself.

January 4: Around 1:00 the nurse said she was going to irrigate Mark’s rectal tube. By 5:20 it hasn’t been done and now there is poop all over Mark and in his bed.

January 4: When I get back Mark has vomited (~9:30) ~ and of course the nurse is nowhere to be found AND this is in an ICU. Mark’s tracheotomy patch is moved to the side and the respirator machine is alarming constantly. I had asked the nurse about 7:00 am to get some washcloths and towels so I could clean his face (these still aren’t in the room at 9:30). I have to push the nurse alarm on the remote ~ and about 15 minutes later she finally arrives. By then I have tried to clean up the vomit as best I could. The nurse finally arrives and says “she has to go and take care of the next door patient’s iv’s before she can get back.” I ask her to call respiratory (because of the vomit near the tracheotomy tube) ~ she says they won’t be here until 10:30. The respirator is alarming continuously. I tell the nurse something is wrong, she says Mark has to stop moving. I tell the nurse ~ once again ~ that he is in pain and if she was in that much pain she would be moving too. I also tell the nurse that I disagree with her that the respiratory alarms are something that just happened because Mark is moving ~ this starts after Mark vomits. The nurse is clearly upset and goes and gets
Dr. William Park (I assume). Dr. William Park comes in, I tell him about the vomit, and he sees that the tracheotomy is in a poor position causing it to continuously alarm and adjusts it. Now the alarms stop, even though Mark is still moving around. All this was a simple root cause analysis - and this nurse is qualified to work in an ICU?

January 7: Rounds with
Dr. William Park: He wants to know why he wasn’t called when Mark’s heart stopped beating last night; they don’t know.

January 14: Mark is undergoing CVVH DF; a dedicated Rn is required (1:1). Nurses have back-ups assigned when they need to leave the area, go to lunch, etc. Gina (my sister) goes out into the hallway (the CVVH DF alarms are sounding) to find the nurse. It takes over 5 minutes to locate one.

December 14: Day 2 and the wound nurse doesn’t show up again (Laura Force). I leave a message on the white board: I take off the bandages on Mark’s ears; the skin and bandages are green. This is very alarming. I also want to know what the plan is for the bedsores (do they want me to buy equipment for Mark and bring it to his room?)

Other issues I noted:

December 7: I notice today when the respirator guy comes the room in that Mark’s stare follows him. Mark’s right hand shakes and goes up in the air like he wants to grab him. The guy laughs and makes a comment.

December 30: Mom says Dan the Rn is very rough

January 4: I’m waiting in the waiting area for my son to have the new G-tube and liver biopsy completed. All of sudden I hear a ton of respirator alarms sounding. I gather up my stuff because I know that Bev, the respiratory tech, and my son are nearby (and I don’t see either of them). Soon, the radiologist,
Dr. Mark Justus, comes out of the room and I tell him I knew my son was out of the procedures, and Bev nearby, because of all the alarms going off. He looks at me surprised because I am correct.

2 comments:

  1. Anonymous2:08 PM

    You want pain med, you don't want pain med. Sounds like there was no winning with you. You seem highly critical of mineutia. It's no wonder nurses stayed out of the room.

    ReplyDelete
  2. You poor thing – not only is English not your first language but I believe you are on the wrong blog. I won’t get caught up in your minutia (me want pain med, me don’t want pain med??? Yikes). What is interesting is that the good nurses (and there were many) never had issues coming into the room – only a couple. Actually, I should post a page for the VMC nurses and give them my reviews. It’s going to be very hard though because there were so many good nurses there. It only takes a couple of bad apples to spoil the bunch (that’s a statement we make here in the US). Hope you find the right blog soon!

    ReplyDelete